Dental Insurance is Essential, But Not Enough 

By Myron Allukian, Jr., DDS, MPH


Closing the Gap, Oral Health • July 1999


While more than 43 million Americans lack medical insurance, there are over 150 million Americans with limited or no dental insurance, according to the Office of Disease 

Prevention and Health Promotion, U.S. Department of Health and 

Human Services (HHS). Unlike medical conditions, dental diseases 

affect almost the total population, 

with nearly everyone needing dental care. For example, 84 percent of 

17 year-olds have had tooth decay, 

with an average of 8 affected tooth 

surfaces; and 99 percent of 40-44 

year-olds have had tooth decay, with 

an average of 30 affected tooth surfaces. 

Those most likely not to receive 

needed dental services are the vulnerable or high-risk population 

groups, such as the low income, the 

least educated, racial and ethnic minorities, immigrants, the developmentally and medically compromised or disabled, the elderly, persons with HIV, and the uninsured. 

For example, lower income children have almost five times more untreated dental disease than higher income children, according to the 

National Health and Nutrition Evaluation Survey III. 

How much are we spending on dental services? 

Although $50.6 billion was spent for dental care in the U.S. in 

1997, a majority of Americans don’t have dental insurance. According 

to the Health Care Financing Administration (HCFA), 47 percent of 

dental services are paid for out-of-pocket. (See Table 1.) Only 4.4 

percent of dental care expenditures were from public funds, with 

most it (roughly 4 percent or $2 billion) being from Medicaid. 

Lack of dental insurance affects dental utilization and oral health 

status. For example, 48.2 percent of people without private dental 

insurance did not have a dental visit in the last year, compared to 28 

percent with insurance, according to data from Dental Services and 

Oral Health: United States, 1989. Of people who had dental visits, 

those without private dental insurance had 1.7 visits a year, compared 

to 2.8 for those with insurance; and 27 percent of persons over 65 

without dental insurance had no teeth at all, compared to 18.3 percent with dental insurance. 

Dental Medicaid 

Even when high risk groups have dental Medicaid, 

they may not receive needed dental care. For example, 

according to a 1996 study done by the U.S. Inspector 

General, more than 80 percent of the 21.1 million Medicaid-eligible children did not receive preventive dental services. 

The six states with the highest proportion of Medicaid-eligible 

children who did not receive preventive dental services were Arizona 

(99.7 percent), Hawaii (99.3 percent), New Mexico (93.8 percent), 

North Dakota (92 percent), Montana (91 percent), and Kentucky 

(90.6 percent). 

The six states with the lowest 

proportion of Medicaid-eligible children who did not receive preventive 

dental services were New Hampshire 

(55.2 percent), Wyoming (56.7 percent), Indiana (59 percent), Kansas 

(64.6 percent), Oregon (65.3 percent), and Nebraska (66.5 percent). 

Unfortunately, too many low 

income children, over 16 million, are 

not receiving dental care even though 

they have dental insurance coverage 

through Medicaid. Even for the state 

with the highest dental utilization 

of Medicaid in our country, New 

Hampshire, 55.2 percent of Medicaid-eligible children did not receive required preventive dental services. Some studies have even shown 

that children with dental Medicaid have worse oral health status than 

low income children without dental insurance. 

The Inspector General’s report states that the reasons few children received dental care were complex, but there were three major 

reasons: 1) few dentists serve Medicaid children; 2) Medicaid families 

give dental services a low priority; and 3) the youngest children are the 

most difficult to serve and frequently are not screened at all. (See 

Table 2.) 

The American Academy of Pediatric Dentists recommends that 

dentists examine all children before their first birthday. However, 

99.6 percent of these children did not receive these services even 

though 20 states have adopted this standard, 12 states recommend 

screening at age 2 years, and the rest at age 3 years. 

Unfortunately, dental care is an optional service for adults in the 

Medicaid program. Vulnerable adult population groups like the homeless, homebound, elderly, minorities, uninsured, low income, persons 

with HIV, and medically compromised or disabled have even greater 

difficulty accessing dental services. 

The reasons given for dentists not participating in Medicaid, 

according to this report were low fees, slow payment, arbitrary denials 

and requirements for prior authorization for routine care. Also, many 

dentists had difficulty treating Medicaid families and general dentists 

didn’t wish to treat younger children. From the family perspective, 

oral health was a low priority given other needs, and families were 

unwilling or unable to wait, travel, or obtain child care 

for dental appointments. 

continued on page 2>>>> 

Table 1. U.S. Dental Care Expenditures, 1997 

Total $50.64 billion 

Private Funds $48.37 billion (95.5%) 

Private Insurance 24.25 billion (47.9%) 

Out-of-Pocket 23.86 billion (47.1%) 

Public Funds $ 2.27 billion (4.4%) 

Federal Medicaid 1.12 billion (2.27%) 

State/Local Medicaid .87 billion (1.7%) 

Medicare .07 billion (0.1%) 

Source: Health Care Financing Administration, 1999. 

Office of Minority Health Resource Center 1 U.S. Department of Health and Human Services 
Dental Insurance is Essential, But Not Enough 

By Myron Allukian, Jr., DDS, MPH


Closing the Gap, Oral Health • July 1999


The Medicaid dental problems have been acknowledged by some 

decision-makers on the state and national levels. However, progress 

had been slow. In some states, such as California, Connecticut, Maine, 

Pennsylvania, and more recently New York, legal suits have forced 

states to improve Medicaid programs. In other states such as Arizona, 

Indiana, Massachusetts, Nebraska, North Carolina, Oklahoma, Pennsylvania, and Virginia, oral health 

the Health Resources and Services Administration (HRSA), have an 

oral health initiative to improve access to the underserved by stimulating statewide planning and providing technical assistance and some 

modest funding. 

HCFA and HRSA also sponsored a dental workshop for state 

Medicaid directors and other interested parties in 1998 to help impartnerships, coalitions, constitu- Table 2. Percent of Medicaid-Eligible Children Who Did 

Not Receive Preventive Dental Services, by Age, 1993

All ages <1 year 1-5 years 6-14 years 15-20 years 

80.3% 99.6% 84% 70% 80.5% 

Source: 1996 Report of the Office of Inspector General, 

U.S. Department of Health and Human Services. 

encies, and state legislative actions 

also have helped to improve the 

program. 

Children’s Health 

Insurance Program 

prove the dental Medicaid programs, and a number of strategies and recommendations are 

included in their report. They 

are also trying to provide guidance to the states through their 

regional offices so more high-risk 

populations groups will be 

served. On May 25, 1999, Vice 

There were 11 million President Gore approved a new

American children who had no health insurance in 1997, of which 

about 3 million were eligible for Medicaid, according to the Institute 

of Medicine. Congress passed the Balanced Budget Act of 1997 which 

included provisions for the State Children’s Health Insurance Programs (CHIP). The bill originally included dental services, but by the 

time it passed Congress, dental services were optional and could only 

be included at the discretion of individual states. 

The nature of the CHIP program is determined by each individual state upon approval by HCFA, and it may be an expansion of 

the state’s existing Medicaid program, a new separate program, or a 

combination of Medicaid expansion and a new separate program. 

About $25 billion in federal money for all health services will be 

available to the states for this initiative over a five-year period. 

Dental Services in CHIP 

As of April 1999, 48 states have submitted CHIP proposals to 

HCFA and all but three, Delaware, Colorado, and Montana, have 

some dental services. Florida’s plan only provides dental services for 

children up to age 5 years. Of the 48 state proposals, 18 (plus Washington, D.C. and Puerto Rico) include dental in an expanded Medicaid program under CHIP, 8 include dental in a separate CHIP 

program, and 18 states include dental in a combination of both. 

The scope of dental services varies and dental partnerships, constituencies, coalitions, and legislation on the state level can help improve the dental benefit package in the CHIP program. CHIP dental 

programs built upon the Medicaid program can only be successful if 

the Medicaid programs are expanded, upgraded, and improved. 

Other Initiatives 

HHS’s Healthy People 2010 has national objectives to help close disparities in oral health status among 

high-risk populations. Two federal agencies, HCFA and 

Department of Justice regulation assuring families that immigration 

status will not be affected for those who enroll in Medicaid or CHIP 

and/or who receive other benefits such as school lunch or child care. 

This will help reduce a potential barrier to dental care for some cultural and linguistic minorities. 

Recommendations 

Studies have shown that the financing of dental care by itself 

does not ensure that the oral health of a population will improve. 

Unfortunately, the dental Medicaid program is a prime example of 

this failure. Although improving the financing of dental care is essential, the following must also be done to improve oral health status in 

our country. 

1.	 Oral health must be a much higher priority on the local, state, 

and national levels. 

2.	 The dental component of Medicaid and CHIP must be upgraded, expanded, and improved. 

3.	 Special initiatives must be promoted and implemented for vulnerable and high-risk populations including adults, to improve 

their access to dental care. 

4.	 Individual- and population-based prevention services and programs must be promoted and implemented, especially for children and high-risk populations. 

5.	 All communities with a central water supply must be fluoridated. To close the gap for a healthier America, we must all work 

together to respond to the neglected epidemic of oral diseases 

and its neglected financing system.

 Dr. Myron Allukian, Jr. is the director of Community Dental 

Programs for the Boston Public Health Commission.

Office of Minority Health Resource Center	 2 U.S. Department of Health and Human Services